National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Osage Beach, MO

Accident Number:

CEN15LA172

Date & Time:

03/11/2015, 1243 CDT

Registration:

N774TA

Aircraft:

BEECH B19

Aircraft Damage:

Substantial

Defining Event:

Loss of engine power (total)

Injuries:

1 Serious, 2 Minor

Flight Conducted Under:

Part 91: General Aviation - Personal

Analysis

The pilot reported that, shortly after takeoff, he noticed that the oil pressure was dropping. Shortly after the oil pressure dropped, the engine seized, and the pilot subsequently ditched the airplane in a lake.

When the airplane was recovered, the oil dipstick was missing. However, more than 4 quarts of oil and only about 1 to 2 cups of water were drained from the engine. If the dipstick had not been in the engine at impact, the engine would have been full of water. Further, the pilot reported that he had replaced the dipstick after checking the oil; so, the dipstick likely was in place at impact. No signs of oil were found in the engine cowling, and no oil streaks were observed underneath the fuselage. A postaccident examination of the engine revealed that the crankshaft middle bearing had seized. The third bearing aft, which was between the two banks of cylinders, and the No. 3 connecting rod bearing had rotated and exhibited severe heat distress and mechanical damage. The No. 4 piston wrist pin plug was deformed, and the deformation had damaged the side of the piston. Aluminum pieces and shavings were found throughout the engine. It is likely that, as the No. 4 wrist pin plug wore down, its shavings entered the oil system and clogged the oil passages, which caused the engine to seize. The examination also revealed that the engine parts installed on the airplane, including the No. 4 piston wrist pin plug, were not approved by the engine manufacturer.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The failure of the No. 4 piston wrist pin plug and the subsequent entry of its metal shavings into the oil system, which clogged the oil passages and caused the engine to seize. Contributing to the accident was the installation of engine parts that were not approved by the engine manufacturer.

Findings

Aircraft

Recip engine power section - Fatigue/wear/corrosion (Cause)

Oil - Fluid condition (Cause)

Recip engine power section - Related maintenance info (Factor)

Factual Information

On March 11, 2015, at 1243 central daylight time, the pilot of a Beech B19, N774TA, ditched in Lake Ozark, Osage Beach, Missouri, after oil pressure was lost and the engine seized. One passenger was seriously injured, but the pilot and another passenger escaped injury. The airplane was substantially damaged. The airplane was registered to GDS Properties and operated by the pilot, both of St. Charles, Missouri, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The cross-country flight originated from Grand Glaize-Osage Beach Airport (K15), Osage Beach, Missouri, about 1225, and was en route to Creve Coeur Airport (1H0), St. Louis, Missouri.

The pilot told a Federal Aviation Administration (FAA) inspector that everything appeared to be normal when he conducted his preflight inspection, although the oil did appear darker than usual. There was 6 quarts of oil on the dipstick and the oil had just been changed two days before. During the engine run-up, all engine instruments were "in the green." Shortly after takeoff, when the airplane had attained an altitude of about 2,800 feet, he noticed the oil pressure was dropping and he turned back towards K15. Shortly thereafter, the propeller stopped and the engine seized. He ditch in Lake Ozark. The occupants exited the airplane and climbed out on the wing. The pilot said that as they awaited rescue, he thought he smelled a twinge of burnt oil.

The FAA inspector examined the airplane and verified there was ample fuel on board, and that it was blue in color. He found the throttle linkage connected. The engine could not be turned by hand. The inspector said he could not find the oil dipstick when the airplane was recovered from the lake. The pilot, however, was adamant that he had replaced the dipstick after checking the oil.

On April 15 and 16, 2015, the engine was disassembled and examined at Dawson Aircraft in Clinton, Arkansas. The oil dipstick was missing, but more than 4 quarts of oil and only 1 to 2 cups of water were drained from the engine.  There were no signs of oil in the engine cowling, and there were no oil streaks underneath the fuselage.

The no. 2 middle bearing on the crankshaft had seized. The third bearing aft between the two banks of cylinders had rotated, and the bearing for the no. 3 connecting rod had rotated. There was evidence of severe heat distress and mechanical damage to the no. 3 rod bearing. The latter had started squeezing out the sides of the connecting rod end.  The no. 4 piston wrist pin plug was deformed and had damaged the side of the piston. Aluminum pieces and shavings were noted throughout the engine. The engine parts appeared to have been manufactured by Superior Air Parts, Inc., and not by Textron Lycoming.

 

History of Flight

Enroute-climb to cruise

Loss of engine power (total) (Defining event)

Emergency descent

Off-field or emergency landing

Landing

Ditching

 

 

Pilot Information

Certificate:

Private

Age:

45

Airplane Rating(s):

Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

 

Instrument Rating(s):

None

Second Pilot Present:

No

Instructor Rating(s):

None

Toxicology Performed:

No

Medical Certification:

Class 2 With Waivers/Limitations

Last FAA Medical Exam:

04/22/2013

Occupational Pilot:

No

Last Flight Review or Equivalent:

 

Flight Time:

(Estimated) 450 hours (Total, all aircraft), 375 hours (Total, this make and model)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

BEECH

Registration:

N774TA

Model/Series:

B19

Aircraft Category:

Airplane

Year of Manufacture:

 

Amateur Built:

No

Airworthiness Certificate:

Normal; Utility

Serial Number:

MB825

Landing Gear Type:

Tricycle

Seats:

4

Date/Type of Last Inspection:

10/30/2014, Annual

Certified Max Gross Wt.:

2150 lbs

Time Since Last Inspection:

18 Hours

Engines:

1 Reciprocating

Airframe Total Time:

2451 Hours at time of accident

Engine Manufacturer:

Lycoming

ELT:

C91A installed, not activated

Engine Model/Series:

O-320-E3D

Registered Owner:

GDS Properties

Rated Power:

150 hp

Operator:

GDS Properties

Operating Certificate(s) Held:

None

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

KAIZ, 869 ft msl

Distance from Accident Site:

6 Nautical Miles

Observation Time:

1235 CDT

Direction from Accident Site:

90°

Lowest Cloud Condition:

Clear

Visibility

10 Miles

Lowest Ceiling:

None

Visibility (RVR):

 

Wind Speed/Gusts:

3 knots /

Turbulence Type Forecast/Actual:

/

Wind Direction:

180°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

30.28 inches Hg

Temperature/Dew Point:

19°C / 17°C

Precipitation and Obscuration:

 

Departure Point:

Grand Glaize, MO (K15)

Type of Flight Plan Filed:

None

Destination:

St. Louis, MO (1H0)

Type of Clearance:

None

Departure Time:

 CDT

Type of Airspace:

Class G

 

Airport Information

Airport:

Grand Glaize-Osage Beach Arto (K15)

Runway Surface Type:

Asphalt

Airport Elevation:

876 ft

Runway Surface Condition:

Dry

Runway Used:

32

IFR Approach:

None

Runway Length/Width:

3205 ft / 60 ft

VFR Approach/Landing:

Forced Landing

 

Wreckage and Impact Information

Crew Injuries:

1 Minor

Aircraft Damage:

Substantial

Passenger Injuries:

1 Serious, 1 Minor

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

1 Serious, 2 Minor

Latitude, Longitude:

38.110556, -92.680556 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

Arnold W Scott

Report Date:

08/25/2015

Additional Participating Persons:

 

Publish Date:

08/25/2015

Note:

The NTSB did not travel to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=90874